Name
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Textable Phone
*
(###)
###
####
Current home town or city
*
How did you find me?
*
Have you seen me before?
*
Email Address
*
Age
18
19
20
21
22
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25
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86
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89
90 +
Height
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
Approx Weight
120 or under
130
140
150
160
170
180
190
200
210
220
230
240
250 or over
Why are you seeking coaching?
How experienced are you with therapy, coaching, bodywork, and/or other transpersonal healing modalities?
Which have you participated in, if any?
Please indicate how much you agree or disagree with the following statements:
I am happy with my life.
I feel good about my body.
I am receiving enough quality touch.
I am happy with my sex life.
Which best describes your relationship to your breath?
If there was one thing I could change about myself it would be:
If there was one thing I could change about my body it would be?
Which best describes your relational status?
If you have a primary romantic relationship, how fulfilling is it?
If you are single, how satisfied are you with your dating life?
Do you suffer from any sexual challenges like premature ejaculation, erectile dysfunction, confidence, sexual anxiety, etc.?
Please describe:
Please feel free to elaborate on any of your answers or discuss topics you may wish to address during our session: